Professional behaviour in medical students and fitness to practise

Much has been written in recent years about the role of the General Medical Council (GMC) in regulating the medical profession and enforcing standards of medical care in the UK.1–3 This role has been thrown into sharp focus by a number of high-profile cases where doctors have abandoned their professional responsibilities and patients have suffered the most serious consequences.4 The GMC has rightly concentrated on developing processes for detecting professional misconduct, including methods of assessment and revalidation, and for appropriately dealing with poorly performing doctors and this work is ongoing.5 However, as Richard Smith, then editor of the British Medical Journal, pointed out in 1997, ‘Although each country must have good systems for detecting, helping, managing and sometimes removing doctors with serious problems, the main emphasis must be on preventing the development of serious problems in doctors.’6 Those of us who work in undergraduate medical schools recognise that we have a responsibility to protect the public from potentially dangerous individuals and have developed fitness-to-practise procedures to deal with those students who demonstrate attitudes and behaviours that suggest they might be unfit to practise medicine. However, problems that require to be addressed by the full formal fitness-to-practise procedures are relatively rare and individual medical schools will have little experience in dealing with them. In my own medical school of around 1250 undergraduate students, we have expelled only 1 student since fitness-to-practise procedures were developed 3 years ago, although several others have received warnings and other lesser penalties. In this context, the GMC and Medical Schools Council (MSC) have issued new guidance entitled ‘Medical Students: Professional Behaviour and Fitness to Practise’, both for use by those involved in medical education and to help raise awareness among medical students of the professional behaviour expected of them.7 The Guidance was produced after the GMC and MSC set up a working group in 2005 to promote high standards of student conduct and bring greater consistency across UK medical schools. The working group consulted extensively, a process that included holding a series of workshops involving all interested groups. The Guidance covers 3 areas: the professional behaviour expected of medical students; areas of misconduct and the sanctions available, and the key elements of student fitness-to-practise arrangements. The Guidance is advisory rather than mandatory but, as the document points out, it would be surprising if a medical school thought it sensible to disregard it.7 It builds on previous publications from the GMC, chiefly Good Medical Practice,8, which represents the GMC’s core guidance for doctors, and Tomorrow’s Doctors,9, which represents its guidance for undergraduate medical education. The Guidance does not consider poor behaviour that may result from underlying health problems, although it indicates that medical schools may wish to use their fitness-to-practise procedures to consider serious health problems.7 It states: ‘A student’s fitness to practise is called into question when their behaviour raises a serious or persistent cause for concern about their ability to continue on a medical course or to practise as a doctor after graduation. This includes, but is not limited to, the possibility that they could put patients or the public at risk.’7 Although the Guidance states that it is the responsibility of medical schools to decide if individual students are fit to practise as doctors by the time they graduate, a helpful table containing a list of some areas of misconduct and concerns identified in fitness-to-practise procedures at medical schools is provided. Some of these are clear-cut. For example, if a medical student receives a criminal conviction or caution for child pornography or theft, then it is clear that fitness-to-practise procedures are required and severe penalties should be imposed. However, other areas are more difficult to judge. For example, how do we determine the threshold for instituting fitness-to-practise procedures when a student demonstrates ‘poor time management’ or that he or she is ‘uncommitted to work’? The Guidance reiterates the opinion that each medical school will only deal with a small number of cases through its formal procedures and thus it was not considered practical to produce an exhaustive list of examples and outcomes. Rather, it states that the behaviour of students must be considered on a case-by-case basis by fitness-to-practise investigators and medical school panels. It also states that it is important to consider whether the behaviour is better dealt with through student support and remedial tuition than through a formal panel hearing. I believe that this Guidance will be very useful in ensuring that there is consistency across UK medical schools in the procedures adopted to deal with fitness-to-practise issues. However, it may not be as useful in ensuring consistency in the judgements made about the level or degree of risk of a particular behaviour demonstrated by a student and the appropriate penalty. This is not a criticism of the Guidance as we simply cannot predict whether a particular behaviour demonstrated by a medical student will translate into unprofessional behaviour as a practising doctor, although a repeated pattern of poor professional behaviour as a student may be expected to be more predictive of future unprofessional behaviour. Despite the importance of these issues, there is little previous research evidence to help us to decide if a particular unprofessional behaviour is likely to indicate future poor professional performance and require expulsion from medical school or if some remedial action is possible. One study examined graduates from a single medical school disciplined by the Medical Board of California over a 10-year period from 1990 to 2000 and found that 95% of disciplinary actions were for deficiencies in professionalism.10 This study found that disciplined doctors were twice as likely as a control group to have ‘Concern/Problem/Extreme’ excerpts in their medical school files. In a further study by the same group of researchers, 3 types of unprofessional behaviour were significantly associated with later disciplinary procedures: poor reliability and responsibility; lack of self-improvement and adaptability, and poor initiative and motivation.11 However, comments about unprofessionalism in the students’ medical school files had a low sensitivity and high specificity and so the majority of medical students who received comments about unprofessionalism were not disciplined as practising doctors. The researchers in these 2 studies then collaborated with research groups in 2 other American medical schools to conduct a case−control study to find out if their results were generalisable.12 They again found that disciplinary action by a medical school board was strongly associated with prior unprofessional behaviour in medical schools, with severe irresponsibility and severely diminished capacity for self-improvement most strongly linked to disciplinary action. It was interesting that this study also found that low scores on the Medical College Admission Test and poor grades in the early years of medical school were also associated with disciplinary action by a medical board, although the associations were much weaker than they were for unprofessional behaviour while at medical school. These researchers called for initiatives to ensure that professionalism has a central role in medical training. There is a huge and complex research agenda that needs to be addressed to provide an evidence base to help medical schools make the difficult judgements about how to deal with poor attitudes and behaviour in medical students. Research questions include: What is the relationship between poor professional behaviour as a medical student and poor professional performance as a practising doctor? Is there a consensus among medical schools to determine when less serious types of unprofessional behaviour require the administration of fitness-to-practise procedures? Can admissions procedures do more to ensure that successful applicants will be fit to practise? What kind of professionalism teaching makes a difference to student behaviour? Can remedial teaching make a difference to poor professional attitudes and behaviour and prevent future poor professional behaviour in practising doctors? To address these and other relevant questions, we need more information from both retrospective studies and prospective longitudinal cohort studies. There is also a need to share the experience of cases that have required the application of fitness-to-practise procedures across medical schools so that ‘case law’ can be developed that will help medical school panels make decisions in these difficult cases.